the 2nd annual Cambridge VATS conference

It may only be the second annual Cambridge VATS conference but Dr. Marco Scarci has managed to assemble one of the finest assortments of speakers in one short course since the days of the original giants. This included a roster of the biggest names, publishers of innovative research and the Masters of Minimally Invasive Surgery including Gaetano Rocco, Alan Sihoe, Joel Dunning, Thomas D’Amico, Henrik Hanson and Diego Gonzalez Rivas.

However, one of the standout presentations was given by none other than Dr. Guillermo Martinez, an Argentine anesthesiologist from Cambridge’s own Papworth hospital. He immediately leapt into one of thoracic surgery’s more controversial topics, nonintubated thoracic surgery. While Dr. Martinez primarily focused on the nonintubated but heavily sedated (or generally anesthetized patient with LMA for airway support) he gave an excellent presentation on the anesthetic considerations for nonintubated surgery. As he explained, it’s a natural progression for nonintubated surgery and VATS go hand in hand, as surgeries become less traumatic to patients, the anesthesia should be less invasive as well. He discussed the rationale for nonintubated surgery from an anesthesiologist’s perspective and outlined the practices at Papworth Hospital where he is part of the thoracic surgery team.

He also discussed the many challenges posed by this method of patient management including the fact that anesthetic techniques for nonintubated surgery need to be reproducible, safe and feasible for eligible patients. Anesthesiologists and thoracic surgeons also need to pre-establish criteria for conversion (such as heavy bleeding, patient hemodynamic instability or conversion to open surgery) to general anesthesia prior to cases, and to be fully prepared to perform urgent intubation as needed.

He also touched on the methods of analgesia used during these cases such as adjuvant like local anesthesia (chest wall infiltration), regional blocks and thoracic epidurals as well as cough suppressant mechanisms.

Reigniting controversey

This along with Dr. Diego Gonzalez Rivas’ subsequent presentation on uniportal surgery combined with nonintubated and awake thoracic surgery reignited much of the firestorm that we first saw at the Duke conference.

Dr. Diego Gonzalez Rivas

Commentary by Dr. Eric Lim perfectly captured some of the sentiments of younger members of the audience, when he took the stage as part of a separate debate on the merits of VATS versus SART when he stated, “I am tired of surgeons calling [new techniques/ technologies / treatments] crap when they’ve read the papers and seen the videos [demonstrating the procedure]. It’s not crap – if you just watched it.” He continued to address the resistance to change in surgery, and the attitudes of surgeons unwilling to adapt. It was a refreshing moment of forthrightness and candor that has been sorely missing from many events. It was also a 180 degree perspective from many of the more critical and conservative attitudes that liken techniques like nonintubated, awake anesthesia or uniportal surgery as being a type of showmanship rather than real innovation, or critics who question the relevancy of pursing research in this area with the “just because we can do it, should we?” mantra that has pervaded many of the recent surgical discussions.

Dr. Wang explained how the research and lessons learned from the Shanghai Pulmonary Hospital has authenticated the uniportal VATS technique to many surgeons in China. He presented original data from his facility on over 1500 uniportal cases.

While he and his colleagues initially debated the safety of this procedure, after learning this technique, it has been adopted throughout Shanghai Pulmonary Hospital. He and the 39 other surgeons on staff use this technique every single day. In fact, the sheer volume of cases at Shanghai Pulmonary Hospital has made these surgeons some of the most experienced uniportal surgeons in the world. After the first uniportal VATS case was performed at SPH in 2013, the technique has rapidly gained popularity. Last year (2014), surgeons at SPH performed 6855 cases, with uniportal cases comprising 50% of all cases. That percentage will only grow, as this year, the hospital is on target for over 8000 cases.

Cambridge 2016?

Now, with such a great entree, what will be the encore for 2016? It would be great to see more “micro-invasive surgery” like a serious sit-down debate among the Awake Thoracic Surgical Group, Gonzalez Rivas, Hung et. al and the traditionalists on the merits of nonintubated surgery along with presentation of more original research, on-going projects and a meta-analysis of the work to date in this area.

It would be interesting to hear more from Dr. Scarci himself, who has been responsible for bringing these surgical innovations to the NHS specialty hospital in Cambridge. Like Dr. Alan Sihoe, who spoke during this session on how to start a uniportal program, Dr. Scarci himself undoubtedly has some excellent experience and insights to share.

More subxyphoid, including bilateral surgical case presentation or a live surgical case also top the wish list here at Thoracics.org.

That doesn’t mean that all of the old standards should be phased out – Henrik Hanson’s standardized approach to 3 port VATS is a classic, for good reason. As Dr. Hansen said himself, “The Gold Standard should not be what Diego [Gonzalez Rivas] or I can do, but a safe, standardized approach.” Not every surgeon is ready to embrace subxyphoid or uniportal approaches, and particularly for surgeons in the twilight of their careers, maybe they shouldn’t. But there is certainly no excuse for any thoracic surgeon on the planet not to excel at traditional VATS.

Topics that should be retired include debates on whether VATS of any approach respects oncological principles, and many of the topics in Robotic surgery. If it’s anyone but Dr. Robert Cerfolio or Dr. Mark Dylewski, then there’s probably not much that they can add to the topic. For everyone else, robotic surgery remains more of an expensive surgical toy than a legitimate area of research. In that vein, less presentations on developing toys and more guidance to the younger audience on transitioning from case reports to more academic research would make for a nice change. If we are going to continue to promote minimally invasive surgery, that we should encourage more advanced research; like the development of more randomized or multi-site trials on topics in this area.